Abstract

Background The levels and experiences of harassment of people with
mental health problems in the community compared with those of the general
population have not been explored.

Aims To measure the levels and experience of harassment experienced
by people with mental health problems in the community in Scotland and compare
them with the general population.

Method Experiences of harassment were collected by interviewing 165
individuals with mental health problems and a control group of 165 people from
the general population.

Results Harassment in the community was found to be twice as common
for individuals with mental health problems (41%) than for those in the
general population (15%). The harassment commonly involved verbal abuse
referring to the individual's mental health problems and was committed
primarily by teenagers and neighbours.

Conclusions Harassment has a significantly higher prevalence among
individuals with mental health problems living in the community and is
believed to have a detrimental effect on mental health.

Stigma and discrimination have long been problems for people with mental
health problems living in the community, and are currently the focus of
campaigns by, among others, the Royal College of Psychiatrists
(2001) and the Department of
Health (2001). This research
was prompted by concerns from mental health organisations hearing anecdotal
accounts of individuals experiencing harassment in their communities. No
previous research explored the prevalence of such harassment, particularly in
comparison with the general population and across different communities. Only
one study, carried out for MIND, had examined harassment previously, finding
that 50% of its respondents had experienced harassment in the workplace and
community (Read & Baker,
1996). The study was limited, however, by its use of a
self-selecting sample. Kelly & McKenna
(1997) found that 60% of their
sample (in a quality-of-life study) experienced harassment, the majority
living in local authority ‘difficult to let’ areas.

METHOD

Definition of harassment

There is no single definition of harassment: it can take a variety of
forms, both verbal and physical, and have a variety of motives. It can be
conducted by one person or a group of people, against one person or several.
The impact of a specific behaviour will be different depending on the
individual who experiences it; additionally, perpetrators of harassment may
not see their behaviour as causing distress to others.

For the purposes of this research, harassment was defined as:

a person carrying out an action that may reasonably result in another
feeling harassed;

the act need not necessarily be repeated;

the perpetrator need not necessarily have acted with intent.

For the purposes of the study, community-based harassment embraced
harassment both within and outside of the home, but excluded workplace
harassment, childhood abuse and domestic abuse.

The Multi Centre Research Ethics Committee for Scotland and the appropriate
local research ethics committees granted ethical approval for the study.

Sample

Study areas

The four types of area that were sampled were those typical in
Scotland:

cities (Aberdeen, Glasgow and Dundee);

towns (East Kilbride, Hamilton, Falkirk and Cumbernauld);

peripheral housing estates (Drumchapel and Castlemilk, both peripheral to
Glasgow);

scattered rural settlements (Dumfries and Galloway).

Each site was served by one or more community mental health teams through
which the sample was accessed. It was not the intention to make systematic
comparisons between the different localities.

A total of 165 individuals with mental health problems and 165 individuals
in the general population were interviewed. Each sample comprised interviews
with 40 people from each of cities, towns and rural settlements and 45 from
peripheral housing estates.

Inclusion criteria

The individuals with mental health problems were experiencing severe and
enduring mental health problems as defined by the Scottish Framework for
Mental Health Services (Scottish Executive,
1997). The assumption was that the mental health problems of these
individuals would have had more impact on their lives than those of
individuals who had experienced a single episode or problems of a more
transient nature. The age range was between 25 and 65 years.

Exclusion criteria

People with dementia were excluded as being a distinct group with
particular needs. Homeless people also were excluded from the sample. It was
considered that the nature of this population, including high incidences of
mental health problems, would lead to difficulties in providing a matched
sample. In the general population, those who had been in contact with mental
health services within the past 10 years were excluded.

Research instruments

A face-to-face interview was chosen to provide a safe environment within
which the complex issues of harassment could be explored. The interview was
structured in format but allowed less structured responses when taking
descriptions of any incidents of harassment. The interview schedule was
developed after a series of focus groups involving people using mental health
services in both the voluntary and statutory sectors. The same interview was
administered to both sample groups.

The interview provided socio-demographic information. Interviewees were
asked if they felt that they had experienced harassment and, if so, they were
asked to describe their experiences. The interviewers recorded the
experiences, using prompts to ensure that information was gathered about what
the harassment consisted of, where it had taken place, who was committing it,
why it was felt to be occurring and the impact it had on the interviewee.

Procedure

Each community mental health team was approached and asked to access a
sample of its users. Service users meeting the inclusion criteria were
approached by their community psychiatric nurse and asked if they would be
prepared to be interviewed. If consent was given, they received an information
sheet and their details were passed to the researcher. The researcher then
contacted them to arrange the interview. All participants were interviewed in
their own homes or at their resource centre. The general population was
assessed by interviewers calling at their homes and matching them on gender,
age and type of housing.

The data were collected between June 2000 and March 2001. A team of eight
specifically trained interviewers carried out the interviews.

Analysis

The quantitative data were analysed using MINITAB, Version 12 for Windows.
Comparisons between subgroups were made using the χ2 test. The
qualitative data were analysed using QSR NUD*IST.

RESULTS

A total of 330 people were interviewed: 165 people with mental health
problems and 165 people in the general population.

Socio-demographic characteristics

Table 1 reports the
socio-demographic characteristics of the two samples, including gender, age
and employment status. If they were unemployed, they were asked how often they
went out of the home. The table gives information about the type of property
the participants lived in, whether they lived alone and the length of time
they had lived in both their property and the area.

There was a significant difference between the numbers of people in
employment in the two groups: 53% (n=88/165) of the general
population were employed or were students compared with 5% (n=9/165)
of people with mental health problems. All those with mental health problems
(n=6) and 35% (n=29/84) of those in the general population
who were employed worked part-time. Those who were unemployed
(n=233/330) were asked how often they went out of their homes. Eighty
per cent or more of both samples said that they went out either on a daily
basis or several times each week. Forty-five per cent (n=45) of the
people with mental health problems lived alone, which was 30% more than in the
general population (n=25).

The ownership of property differed between the groups: 21% (n=93)
more people with mental health problems lived in local-authority-owned
accommodation than in the general population (n=60). Over 70% of both
samples (sample with mental health problems, n=121/165; general
population sample, n=117/165) had lived in their area for over 20
years.

Levels of harassment

Table 2 shows the overall
reporting of harassment and where the harassment occurred. Sixty per cent
(99/165) of people with mental health problems and 44% (73/165) of the general
population reported experiencing some form of harassment
(χ2=8.21, P=0.004). Figures for incidences of
harassment in the workplace and bullying while at school are detailed in
Table 2 but are not included in
the full analysis. There was a significant difference in the overall levels of
harassment between the individuals with mental health problems and the general
population. There was a significant difference in the location of the
harassment, with 41% (67/165) of people with mental health problems
experiencing harassment in the community compared with 15% (24/165) of the
general population (χ2=20.42, P<0.001). People from the
general population were more likely to have experienced harassment in the
work-place, reflecting the higher number of this sample in employment
(χ2=13.33, P<0.001).

The results reported below refer only to the harassment experienced in a
community setting.

Socio-demographic characteristics and harassment

There were three socio-demographic variables showing significance. As can
be seen in Table 3, age showed
a significant influence on whether a person with mental health problems had
experienced harassment, although this was not the case in the general
population (χ2=8.77, P=0.033). When the two samples
were combined an influence was shown but, because it was a weak level, it was
not thought to be reliable (χ2=8.40, P=0.038). A
significant association between people living in local authority accommodation
and the prevalence of harassment was evidenced within the general population
sample and when both samples were tested.

The type of area in which people lived did not influence whether they were
likely to experience harassment or not. The prevalence of harassment between
the two samples differed to the same extent across all areas (between 27% and
30%), except in the cities, where it was 17%. People living on their own were
not significantly more likely to have experienced harassment, although there
was a higher prevalence across both samples. A lower (but not significant)
number had experienced harassment while living in supported accommodation
compared with those people living in mainstream accommodation.

Features of harassment

Table 4 shows that in both
samples verbal abuse was the most common form of harassment. There was one
feature specific to the people with mental health problems that over half of
the sample described: having those problems exposed. This happened most
commonly alongside verbal abuse. People frequently spoke of being called
derogatory names:

‘...they waited for me and followed me again, they were calling me
names such as “loony” and saying “you should be locked
up”’. (Woman, 25-34 years, Dundee)

Unwanted interference frequently was reported, taking various forms
including false accusations to the authorities or nuisance telephone
calls.

‘I started getting telephone calls about two and a half years ago.
Groups of kids and young people were making calls to my house. They had found
out I was on my own and I was fair game.’ (Man, 45-54 years,
Aberdeen)

The general population also described similar incidents:

‘On Friday night, two days ago, our window was broken by a gang of
teenagers who are targeting us.’ (Man [general population] 35-44 years,
Cumbernauld)

Other features of harassment that interviewees described included being
physically threatened and, on occasion, actually assaulted.

Who was committing the harassment

Teenagers and neighbours were the two groups most frequently mentioned as
committing the harassment across both samples and all types of area. The
teenagers committing the harassment were often in groups of two or more:

‘It was mainly young people about the streets aged about 14 or
15.’ (Man, 44-55 years, Drumchapel)

The harassment from teenagers predominantly consisted of verbal abuse; they
were largely thought to commit harassment as a result of influence from either
their parents or peers. Teenagers' ignorance of mental health problems also
was given as a reason for their behaviour.

The general population also described harassment from teenagers:

‘they hang around in my close [communal stair-case] drinking and
using abusive language at all hours and throwing stones at my windows.’
(Woman [general population], 25-34 years, Castlemilk)

Neighbours also primarily committed verbal abuse:

‘Two neighbours, one I had helped in the past, laughed at me and made “
mental” signs at me.’ (Woman, 55-65 years, Drumchapel)

The finding that 21% of the interviewees with mental health problems had
experienced harassment coming from within their families was unexpected;
nobody from the general population spoke of harassment coming from within
their family:

‘My brother-in-law used to harass me for my sleeping tablets.’
(Man, 35-44 years, East Kilbride)

This harassment was not as a result of ‘overanxious’ carers
reminding people to take medication: it was of a specifically malicious
nature. People described being taken advantage of for their welfare benefits
or medication, the relative knowing that they felt unable to stand up for
themselves. They also felt that their mental health problems were often
referred to, with family members calling them names and making derogatory
references to their mental health:

‘It sounds stupid but I had ECT [electroconvulsive therapy] treatment
for my depression and members of my family, especially my sister, thinks it's
funny. She calls me “sparky”. I find it very hurtful and I've
tried to talk to them but she keeps on about it.’ (Man, 55-65 years,
Dundee)

Why people felt that they were experiencing harassment

There were substantial differences between the samples in the reasons why
people felt that they were experiencing harassment. When the people with
mental health problems knew the person committing the harassment, the majority
felt that it was happening because they were known to have mental health
problems:

‘They do it because they don't understand mental health
problems.’ (Woman, 45-54 years, Castlemilk)

The majority of people in the general population saw the motive for the
harassment as fulfilling a need of the harasser, such as to try to get money
or, in the case of teenagers, looking for something to do:

‘Children do it for sheer devilment, they want to annoy
somebody.’ (Woman [general population], 55-65 years, Drumchapel)

When the motive for the harassment was felt to be mental health problems,
vulnerability or the person being different in some way, the most frequent
feature of the harassment was verbal abuse, often in conjunction with exposing
the mental health problems.

Reporting the harassment

For the purposes of this study the reporting of harassment was both formal,
for example to the police, and informal, for example to medical or support
staff. People with mental health problems were more reluctant to report
harassment than were the general population. Nearly three-quarters of the
general population (n=17/24, 71%) went to the police, compared with
just under half of the people with mental health problems (n=29,
43%).

There are several potential reasons why people with mental health problems
may be reluctant to involve the police. There may be a fear that they will not
be taken seriously and that the complaints they wish to make will be seen as a
manifestation of their mental health problem. Because the police often can
become involved with people with mental health problems under the Mental
Health Act, individuals also may be wary of having voluntary contact,
especially if they have had a negative experience in the past:

‘The police have targeted me - I think they don't realise that I am
ill. Last time I was admitted they had to come for me... I don't like the
police, I try to tell them when I am high.’ (Man, 55-65 years,
Falkirk)

The majority of people reported the harassment to more than one agency and
nearly half of the people with mental health problems also told medical or
support staff about their problems:

‘I reported it to my CPN [community psychiatric nurse] butthere is
nothing my CPN can do about it’. (Woman, 55-65 years, Drumchapel)

The majority of both groups found that reporting the harassment made no
difference. This may make people reluctant to report further incidents to the
police, which will have an impact on the monitoring of incidents that allows
the police to target their services most effectively.

Although the general population reported the harassment more frequently,
some had fears of repercussions if they involved the police:

‘I was going to go to the police but I was worried it would cause
more hassle.’ (Woman [general population], 35-44 years, Drumchapel)

Strategies to try to stop harassment

Strategies included any action at all taken by the person other than
reporting it. Over one-third (n=31, 46%) of the people with mental
health problems took no action to attempt to stop the harassment. If they did
take action it was the act of moving house; in fact, more people with mental
health problems had moved house (n=20, 30%) than had tried to reason
with the harasser (n=11, 16%):

‘I applied for a move to the housing officer and got moved to where I
live now where I am much happier and don't get any trouble.’ (Man, 25-34
years, Glasgow)

Continuing harassment

Nearly half (n=30/67, 45%) of the people with mental health
problems who had experienced harassment were still experiencing it at the time
of interview. In the general population, the harassment was ongoing for a
similar percentage of those who had experienced it (n=10/24,
42%).

Of the people with mental health problems experiencing continuing
harassment, one-third (n=10/30, 33%) had reported it to the police
and half additionally had reported it to medical professionals or support
staff (n=15/30, 50%). Not surprisingly, the majority of these people
felt that reporting had not made any difference. One-third of people had not
reported the harassment at all.

Impact of harassment

Almost all the interviewees with mental health problems referred to the
adverse effect that the harassment had had on their mental health. This was
particularly the case when they felt that they were being harassed as a result
of their mental health:

‘I ended up in hospital virtually every month and my condition became
worse.’ (Woman, 35-44 years, Dumfries and Galloway)

Half of the general population sample in this study who experienced
harassment spoke of a detrimental effect on their mental health.

‘I became very stressed. My hair was falling out and I was very
depressed.’ (Woman [general population], 25-34 years, Aberdeen)

Overall, across the two samples, three-quarters said that their mental
health had been affected.

Anger and annoyance was described most frequently by the general population
(n=21/24, 88%) and second most frequently described by people with
mental health problems:

‘I was very angry and wanted to put their heads through the wall, but
that's no answer.’ (Man, 55-65 years, Drumchapel)

One difference between the responses of the two samples to harassment was
the level of fear in certain circumstances. If the harasser was not known to
the individuals, a higher percentage of the general population talked of being
annoyed than of the people with mental health problems, who more frequently
described fear. Fear also was a common response when individuals felt that
they were being harassed because of their mental health problems. Fear had
resulted in people feeling the need to take actions to defend themselves from
the perceived or actual threat:

‘I actually sat in front of the TV one night with a rolling pin and a
knife because I was worried they would get in and try and hurt me.’
(Woman, 35-44 years, Drumchapel)

A woman interviewee in Drumchapel described a situation where her
neighbours were kicking her door to intimidate her. She had contacted the
police and, while waiting for them to arrive, had picked up a knife. She
describes how, understandably,

‘The police misread the situation; even after I had put down the
knife the attitude from the police was that I was the culprit, not my
neighbour.’ (Woman, 45-54 years, Drumchapel)

Preventing harassment

All interviewees, regardless of whether they had experienced harassment or
not, were asked what they felt would help to stop or prevent harassment. The
responses were very similar across both groups. The most commonly cited
response was ‘education’. This was either education of the general
public, with the aim of increasing knowledge and awareness of mental health
problems, or education about the impact that antisocial behaviour can have on
those who are its victims:

‘Children should be educated so that they learn that people cannot
help being different. The parents need to be educated as well so that they can
stop the children behaving in this way.' (Woman, 45-54 years, Drumchapel)

Intrinsically linked to education, and the second most common response, was
a call for a positive change in public attitudes towards people with mental
health problems.

DISCUSSION

Overall prevalence of harassment

This is the first study to compare the harassment of people with mental
health problems with that of the general population. In total, people with
mental health problems were more likely to experience harassment than the
general population. This study is thus able to support the findings of Read & Baker (1996), who
described half of their respondents experiencing harassment; although the
present study shows a lower overall prevalence, it achieved its sample in a
more representative manner. Because there are a greater number of people in
the general population sample who are in employment, they have more
opportunity to experience workplace harassment. It seems that having mental
health problems leaves people more vulnerable to experiencing harassment in
their communities.

Only three people in this study came from ethnic minorities, therefore
harassment of this group cannot be discussed. It is difficult to obtain
figures for the likelihood of people experiencing harassment for other reasons
such as race or gender, largely owing to the low level of reporting of ‘
low-level harassment’ typified by verbal abuse. However, it is
generally accepted that people from minority ethnic communities experience
widespread racially motivated harassment
(Social Exclusion Unit, 2002).
Our study shows that having mental health problems can be treated also as a
predictor of whether a person is likely to experience harassment.

The requirement by the Multi Centre Research Ethics Committee that
community psychiatric nurses should approach patients may have led to a
selective sample, possibly with a bias towards women and to people they felt
would be more amenable to taking part or more likely to have experienced
harassment. Likewise, because people from ethnic minorities are already known
to use community mental health services less, community psychiatric nurses
might have approached fewer of these people
(Sainsbury Centre for Mental Health,
2002).

Individual differences

Similar amounts of harassment were reported by both genders in both
samples. It might have been hypothesised that women experience more harassment
than men, because of sexual harassment. This may be the case in the workplace
but this study did not find an equivalent within the community. It is not
known why age showed an influence on whether people had experienced harassment
in the community. How frequently people left the house was significant to
whether the general population sample and the two samples combined experienced
harassment. It is felt that it did not prove to be significant for the sample
of people with mental health problems because they experience harassment from
within their own families without necessarily leaving their homes.

Property and location

Although there are many studies exploring public attitudes towards people
with mental health problems in different types of neighbourhood
(Brockington et al,
1993; Huxley, 1993;
Wolff et al, 1996),
they do not explore the actual behaviour of the community. The findings of
this study show that it made little difference where people lived: people with
mental health problems were more likely to have experienced harassment than
the general population, wherever they lived. However, because the combined
samples living in local authority accommodation were significantly more likely
to experience harassment, this seems to indicate that there was a higher
prevalence in lower socio-economic class areas (assuming property tenure as a
proxy for socio-economic status), supporting the findings of Kelly &
McKenna (1997).

Living in supported accommodation has the potential either to draw
attention to a person's mental health problems or to offer some protection
through staff presence. People living in this accommodation were by no means
entirely protected from harassment but it was slightly less prevalent than for
people living in unsupported accommodation.

Features of the harassment

These findings show that for the 41% of people with mental health problems
who had experienced harassment it had had a serious impact on their lives. As
the majority of people with mental health problems are supported within the
community, the experience there has the potential to profoundly affect their
prognosis and overall quality of life. Mental health professionals need to be
aware of these effects and be able to offer support and advice to their
patients with confidence. Practitioners also must be proactive in raising the
subject of patients' community experiences because patients may not recognise
that this is a problem for which support can be provided.

There is an inherent difficulty in trying to identify why people were being
harassed when only having access to the opinion of the victim. Participants
were not asked why they felt they were harassed as a result of their mental
health problems because this was felt to be too sensitive an area. This
information therefore was acquired only if the participant volunteered it. It
could be argued that the people with mental health problems were assuming that
they were being harassed as a result of their mental health problems when this
was not actually the case, or that they expected to be harassed because they
recognised the stigma of their condition. Because almost half of the
harassment that interviewees experienced, particularly verbal abuse,
explicitly referred to their mental health problems, this counters the above
suggestion.

The findings in this study are similar to those of Kelly & McKenna
(1997), with reports of
children and teenagers committing what they termed ‘low-level
victimisation’, including verbal abuse and attacks on property. They
describe a similar scenario where people with mental health problems felt the
need to arm themselves, potentially putting themselves at risk from
prosecution.

There is little previous evidence looking at the impact that harassment can
have on people with mental health problems. This study has shown, however,
that harassment can affect the mental health of people without previous mental
health problems.

The numbers of people moving house in this study had similarities to Read & Baker's (1996) study,
which found that 26% of people with mental health problems experiencing
harassment moved house; this study showed a value of 30% (20/67). Because the
results found no significant variations in harassment across different areas,
this suggests that moving house is no guarantee that the harassment will not
start again.

Anti-stigma campaigns

Because so much of this harassment is thought to occur as a result of
negative public attitudes towards mental illness, continuing anti-stigma work
must be given priority, such as that of the Royal College of Psychiatrists
(2001) and the Department of
Health (2001), as well as that
carried out by devolved government and local initiatives.

With so much of the harassment committed by young people, this group in
particular should be targeted in the most immediate campaigns in order to
counter these negative attitudes.

Clinical Implications and Limitations

CLINICAL IMPLICATIONS

Professionals should be aware that harassment is a problem for a
significant number of people with mental health problems, regardless of the
type of area in which they live. The community experience of patients,
therefore, must be assessed regularly during consultation.

The importance of anti-stigma initiatives at both a local and
national level must be recognised.

Professionals need to have knowledge of where to refer patients
experiencing such difficulties for specific assistance and support within the
context of multi-disciplinary support and multi-agency working.

LIMITATIONS

It is impossible to assess objectively why a person becomes the
target for harassment without having access to the perpetrator.

By its very nature, the experience of harassment is subjective and
people assume a causal relationship between harassment and deterioration in
their mental health when other factors may have played a part.

There was possible selection bias and lack of ethnic minority
representation.

Acknowledgments

We would like to acknowledge Harper Gilmour for assistance with statistical
analysis.

Sainsbury Centre for Mental Health (2002)Breaking the Circles of Fear: a Review of the Relationship between
Mental Health Services and African and Caribbean Communities.
London: Sainsbury Centre for Mental Health.